OPIOID WITHDRAWAL PROTOCOL Clinical Features …

1 Mental Health and Addiction Services: Brief/Social Detox Unit OPIOID WITHDRAWAL PROTOCOL . Clinical Features of OPIOID WITHDRAWAL - detected & monitored using the OPIOID WITHDRAWAL Scale (OWS). Physical signs/symptoms Lacrimation, rhinorrhea, yawning Dilated pupils, nausea/vomiting Diaphoresis, chills, piloerection, mild tachycardia and/or hypertension Myalgias, abdominal cramps, diarrhea Psychological symptoms Anxiety and dysphoria Craving for opioids Restlessness, insomnia, fatigue Onset & Duration of Symptoms Beginning <8 hours from last Anxiety, fear of WITHDRAWAL , craving for drug, diaphoresis, chills, OPIOID use (Peak within 36-72h) lacrimation, rhinorrhea, yawning Beginning 12 hours from last Piloerection, anorexia, dilated pupils, anxiety, irritability dysphoria, OPIOID use (Peak at 72 h)

2 Restlessness, mild-moderate insomnia, tremor, mild tachycardia and/or hypertension, abdominal cramps Beginning 24-36 hours from last Abdominal cramps, diarrhea, myalgias, muscle spasms (esp. in lower OPIOID use (Peak at 72 h) extremities), nausea, vomiting, diarrhea, severe insomnia, violent yawning NOTE: Methadone WITHDRAWAL may take longer to manifest clinically (24-48h from last dose) than WITHDRAWAL from other opioids, but may persist 2-3 weeks or longer Physical WITHDRAWAL symptoms generally resolve by 5-10 days Psychological WITHDRAWAL symptoms (dysphoria, insomnia) may last weeks to months Complications of OPIOID WITHDRAWAL : OPIOID WITHDRAWAL is not life threatening in otherwise healthy individuals. However, the risk of serious medical complications is higher in pregnant women and neonates.

3 O Pregnancy-associated risks: spontaneous abortion, pre-term labour o Neonatal abstinence syndrome: seizures, death if not identified & treated There is a serious risk of flight, suicide (precipitated by anxiety, dysphoria), and overdose on relapse (because patients begin to lose their tolerance to opioids within 3-7 days after last use). IMPORTANT: Continually assess all patients for suicide risk Screen for pregnancy Warn patients about overdose if they resume OPIOID use at previous dose. Developed by: 1. Dr, Peter Butt MD SCFP (EM), Melanie McLeod BSP, ACPR, PharmD Candidate, Christi Becker-Irvine RN. Mental Health and Addiction Services: Brief/Social Detox Unit Step 1: Symptomatic PROTOCOL + Clonidine Symptomatic PROTOCOL Target symptoms Drug Dosing guideline Nausea and vomiting Dimenhydrinate (Gravol ) 50mg-100mg orally (or IM) up to every 4.

4 Hours as needed Prochlorperazine (Stemetil ) 5mg-10mg orally up to every 4 hours as needed Diarrhea Loperamide (Imodium ) 4mg orally for diarrhea, then 2mg orally as needed for loose bowel movements (Maximum dose =16mg/24h). Myalgias Acetaminophen (Tylenol ) 325mg-650mg orally every 4 hours as needed (Maximum dose = 4000mg/24h). Naproxen (Naprosyn ) 500mg orally twice daily with meals for 4. days, then reduce to twice daily as needed Anxiety, dysphoria, Hydroxyzine (Atarax ) 25mg-50mg orally three times daily as needed lacrimation, rhinorrhea Insomnia Trazodone (Trazorel ) 50mg-100mg orally at bedtime x 4 days, then as needed for insomnia Clonidine Dose Monitoring Clonidine oral test dose Check blood pressure (BP) one hour later. If BP<90/60, if marked postural hypotension occurs or if HR<60- do not prescribe further If <91kg (or <200lbs): Check BP prior to each dose and withhold dose if Clonidine orally 4 times daily x 4 days BP<90/60, if marked postural hypotension or Clonidine orally 4 times daily x 2 days dizziness occurs or if HR<60.

5 Clonidine orally 4 times daily x 2 days, then stop Assess OPIOID WITHDRAWAL Score (OWS) at least every 24 hours: If >91kg (or >200lbs): If after 24 hours the OWS is 10-14 (suggesting Clonidine orally 4 times daily x 4 days moderate WITHDRAWAL symptoms)- proceed to step 2. Clonidine orally 4 times daily x 2 days Clonidine orally 4 times daily x 1 day, If after 24 hours, the OWS is >15 (suggesting severe Clonidine orally 4 times daily for 1 day, WITHDRAWAL symptoms)- proceed to step 3. then stop Developed by: 2. Dr, Peter Butt MD SCFP (EM), Melanie McLeod BSP, ACPR, PharmD Candidate, Christi Becker-Irvine RN. Mental Health and Addiction Services: Brief/Social Detox Unit Step 2: Symptomatic PROTOCOL + Intensified Clonidine Intensified Clonidine Dose Monitoring If <91kg (or <200lbs): Check BP prior to each dose and withhold dose if Clonidine orally 4 times daily x 4 days BP<90/60, if marked postural hypotension or Clonidine orally 4 times daily x 2 days dizziness occurs or if HR<60.

6 Clonidine orally 4 times daily x 1 day Clonidine orally 4 times daily for 1 day, then stop Assess OPIOID WITHDRAWAL Score (OWS) at least every 24 hours: If >91kg (or >200lbs): If after 24 hours at step 2, the OWS is >15. Clonidine orally 4 times daily x 4 days (suggesting severe WITHDRAWAL symptoms)- Clonidine orally 4 times daily x 1 day proceed to step 3. Clonidine orally 4 times daily x 1 day, Clonidine orally 4 times daily x 1 day Clonidine orally 4 times daily for 1 day, then stop. Step 3: Symptomatic PROTOCOL + Intensified Clonidine + Phenobarbital Intensified Clonidine + Phenobarbital Clonidine dose Monitoring If <91kg (or <200lbs): Check BP prior to each dose and withhold dose if Clonidine orally 4 times daily x 4 days BP<90/60, if marked postural hypotension occurs Clonidine orally 4 times daily x 2 days or if HR<60.

7 Clonidine orally 4 times daily x 1 day Assess OPIOID WITHDRAWAL Score (OWS) at Clonidine orally 4 times daily for 1 day, then stop least every 24 hours If >91kg (or >200lbs): Clonidine orally 4 times daily x 4 days Clonidine orally 4 times daily x 1 day Clonidine orally 4 times daily x 1 day, Clonidine orally 4 times daily x 1 day Clonidine orally 4 times daily for 1 day then stop. Phenobarbital dose: Monitoring Phenobarbital 30mg-60mg orally twice daily as needed for Hold dose in presence of marked sedation, anxiety and sedation hypotension (BP<90/60), dizziness, ataxia, listlessness Stop if rash develops Step 4: Refer to a methadone prescribing physician - Methadone 10mg orally 3 times daily for 3-4 days, then taper by 10mg/day (5mg/day on final day).

8 Developed by: 3. Dr, Peter Butt MD SCFP (EM), Melanie McLeod BSP, ACPR, PharmD Candidate, Christi Becker-Irvine RN. Mental Health and Addiction Services: Brief/Social Detox Unit - NOTE: Methadone-related deaths have occurred almost exclusively at doses in excess of 30mg/day 10. References: 1. Kahan M., Wilson L. (2002). Managing Alcohol, Tobacco and other Drug Problems: A Pocket Guide for Physicians and Nurses. Toronto: Centre for Addiction and Mental Health (CAMH). 2. College of Physicians and Surgeons of Ontario: Methadone Maintenance Guidelines November 2005. 3. Stolbach A, Hoffman RS. OPIOID WITHDRAWAL in the emergency setting. (Last update: Jan 1/09). 4. Virani AS, Bezchlibnyk-Butler KZ, Jeffries JJ. Clinical Handbook of Psychotropic Drugs 18th Revised Version (2009).

9 5. Meehan WJ, Adelman SA, Rehman Z, et al. OPIOID Abuse. (Updated April 18, 2006). 6. Naranjo, CA, Bremner KE, Pharmacotherapy of substance use disorders. Can J Clin Pharmacol 1994; 2: 55-71. 7. Weaver MF, Hopper JA. OPIOID WITHDRAWAL management during treatment for addiction. (Last update: Jan 1/09). 8. Korsten, TR, O'Connnor PG. Current Concepts: Management of Drug and Alcohol WITHDRAWAL . N Engl J Med 2003; 348: 1786-95. 9. Connery HS, Kleber HD. American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use Disorders, 2nd Edition (2007). Focus Psychiatry 2007; V: 2. 10. Saskatchewan Ministry of Health/ Saskatchewan College of Family Physicians, SMA. Concurrent Disorders and WITHDRAWAL Management Protocols/Guidelines and Services.

10 Updated by the Addictions Medical Advisory Committee 2008. 11. Hauser L, Anupindi R, Moore W. Hydroxyzine for the treatment of acute OPIOID WITHDRAWAL : A Clinical experience. Resident and Staff Physician 2006; 52: 6. Developed by: 4. Dr, Peter Butt MD SCFP (EM), Melanie McLeod BSP, ACPR, PharmD Candidate, Christi Becker-Irvine RN.